The role of visual and direct force feedback in robotics-assisted mitral valve annuloplasty

Effects of a force feedback function in a surgical robot on the suturing procedure

BACKGROUND

Currently, widely used robotic surgical systems do not provide force feedback. This study aimed to evaluate the impact and benefits of a force feedback function on the suturing procedure.

METHODS

Twenty surgeons were recruited and divided into young (Y-group, n = 11) and senior (S-group, n = 9) groups, based on their years of surgical experience. The effect of the force feedback function on suturing quality was evaluated using an objective assessment system (A-LAP mini, Kyoto Kagaku Co., Ltd., Kyoto, Japan). Each participant completed the suturing task on intestinal model sheets with the robotic contact force feedback on and off. The task accomplishment time (s), maximal force (Newton, N) applied to the robotic forceps, and quality of suturing (assessed by A-LAP mini) were recorded as performance parameters.

RESULTS

In total, the maximal force applied to the robotic forceps was significantly decreased with the robotic force feedback switched on (median [interquartile range]: 2.8 N (2.3-3.2)) as compared with when the feedback was switched off (3.4 N (2.7-4.0), P < 0.001). The contact force feedback function did not affect the objectively assessed suturing score (18 points (17.7-19.0) versus 18 points (17.0-19.0), P = 0.421). The contact force feedback function slightly shortened the task accomplishment time in the Y-group (552.5 s (466.5-832) versus 605.5 s (476.2-689.7), P = 0.851) but not in the S-group (566 s (440.2-703.5) versus 470.5 s (419.7-560.2), P = 0.164).

CONCLUSIONS

With the contact force feedback function, the suturing task was completed with a smaller maximal force, while maintaining the quality of suturing. Because the benefits are more apparent in young surgeons, robots with the contact force feedback function will facilitate the educational process in novice surgeons.

The benefits of haptic feedback in robot assisted surgery and their moderators: a meta-analysis

Robot assisted surgery (RAS) provides medical practitioners with valuable tools, decreasing strain during surgery and leading to better patient outcomes. While the loss of haptic sensation is a commonly cited disadvantage of RAS, new systems aim to address this problem by providing artificial haptic feedback. N = 56 papers that compared robotic surgery systems with and without haptic feedback were analyzed to quantify the performance benefits of restoring the haptic modality. Additionally, this study identifies factors moderating the effect of restoring haptic sensation. Overall results showed haptic feedback was effective in reducing average forces (Hedges' g = 0.83) and peak forces (Hedges' g = 0.69) applied during surgery, as well as reducing the completion time (Hedges' g = 0.83). Haptic feedback has also been found to lead to higher accuracy (Hedges' g = 1.50) and success rates (Hedges' g = 0.80) during surgical tasks. Effect sizes on several measures varied between tasks, the type of provided feedback, and the subjects' levels of surgical expertise, with higher levels of expertise generally associated with smaller effect sizes. No significant differences were found between virtual fixtures and rendering contact forces. Implications for future research are discussed.

How does the modality of delivering force feedback influence the performance and learning of surgical suturing skills? We don’t know, but we better find out! A review

Background

Force feedback is a critical element for performing and learning surgical suturing skill. Force feedback is impoverished or not present at all in non-open surgery (i.e., in simulation, laparoscopic, and robotic-assisted surgery), but it can be augmented using different modalities. This rapid, systematic review examines how the modality of delivering force feedback influences the performance and learning of surgical suturing skills.

Methods

An electronic search was performed on PubMed/MEDLINE, Web of Science, and Embase databases to identify relevant articles. The results were synthesized using vote counting based on direction of effect.

Results

A total of nine studies of medium-to-low quality were included. The synthesis of results suggests that the visual modality could be more beneficial than the tactile and auditory modalities in improving force control and that auditory and tactile modalities could be more beneficial than the visual modality in improving suturing performance. Results are mixed and unclear with regards to how modality affects the reduction of force magnitude and unclear when unimodal was compared to multimodal feedback. The studies have a general low level of evidence.

Conclusion

The low number of studies with low methodological quality and low level of evidence (most were proof of concept) prevents us from drawing any meaningful conclusion and as such it is currently unknown whether and how force feedback modality influences surgical suturing skill. Speculatively, the visual modality may be more beneficial for improving the control of exerted force, while auditory and tactile modalities may be more effective in improving the overall suturing performance. We consider the issue of feedback modality to be highly relevant in this field, and we encourage future research to conduct further investigation integrating principles from learning psychology and neuroscience: identify feedback goal, context, and skill level and then design and compare feedback modalities accordingly.

A Force-Feedback Methodology for Teleoperated Suturing Task in Robotic-Assisted Minimally Invasive Surgery

With robotic-assisted minimally invasive surgery (RAMIS), patients and surgeons benefit from a reduced incision size and dexterous instruments. However, current robotic surgery platforms lack haptic feedback, which is an essential element of safe operation. Moreover, teleportation control challenges make complex surgical tasks like suturing more time-consuming than those that use manual tools. This paper presents a new force-sensing instrument that semi-automates the suturing task and facilitates teleoperated robotic manipulation. In order to generate the ideal needle insertion trajectory and pass the needle through its curvature, the end-effector mechanism has a rotating degree of freedom. Impedance control was used to provide sensory information about needle-tissue interaction forces to the operator using an indirect force estimation approach based on data-based models. The operator's motion commands were then regulated using a hyperplanar virtual fixture (VF) designed to maintain the desired distance between the end-effector and tissue surface while avoiding unwanted contact. To construct the geometry of the VF, an optoelectronic sensor-based approach was developed. Based on the experimental investigation of the hyperplane VF methodology, improved needle-tissue interaction force, manipulation accuracy, and task completion times were demonstrated. Finally, experimental validation of the trained force estimation models and the perceived interaction forces by the user was conducted using online data, demonstrating the potential of the developed approach in improving task performance.

Feasible techniques in robotic thoracoscopic repair of congenital esophageal atresia: case report and literature review

Background

Robotic repair for esophageal atresia (EA) using da Vinci system is challenging. Specific surgical techniques need to be explored to overcome the current hurdles.

Case presentation

Two cases with EA (type I and type III by Gross classification, respectively) were repaired using da Vinci robotic system. Step trocar insertion and asymmetric ports distribution techniques were used. The mean weight was 3.2 kg. Operative times were 95 min totally, with the anastomotic time of 27.5 min. Follow-up duration was 12 months. Esophageal fistula reoccurred in one case. None was confirmed anastomotic stricture.

Conclusion

Step trocar insertion procedure and asymmetric ports distribution technique are effective in robotic esophageal atresia.

Robotics and AI for Teleoperation, Tele-Assessment, and Tele-Training for Surgery in the Era of COVID-19: Existing Challenges, and Future Vision

The unprecedented shock caused by the COVID-19 pandemic has severely influenced the delivery of regular healthcare services. Most non-urgent medical activities, including elective surgeries, have been paused to mitigate the risk of infection and to dedicate medical resources to managing the pandemic. In this regard, not only surgeries are substantially influenced, but also pre- and post-operative assessment of patients and training for surgical procedures have been significantly impacted due to the pandemic. Many countries are planning a phased reopening, which includes the resumption of some surgical procedures. However, it is not clear how the reopening safe-practice guidelines will impact the quality of healthcare delivery. This perspective article evaluates the use of robotics and AI in 1) robotics-assisted surgery, 2) tele-examination of patients for pre- and post-surgery, and 3) tele-training for surgical procedures. Surgeons interact with a large number of staff and patients on a daily basis. Thus, the risk of infection transmission between them raises concerns. In addition, pre- and post-operative assessment also raises concerns about increasing the risk of disease transmission, in particular, since many patients may have other underlying conditions, which can increase their chances of mortality due to the virus. The pandemic has also limited the time and access that trainee surgeons have for training in the OR and/or in the presence of an expert. In this article, we describe existing challenges and possible solutions and suggest future research directions that may be relevant for robotics and AI in addressing the three tasks mentioned above.

Haptics in Teleoperated Medical Interventions: Force Measurement, Haptic Interfaces and Their Influence on User's Performance

OBJECTIVES

Haptics in teleoperated medical interventions enables measurement and transfer of force information to the operator during robot-environment interaction. This paper provides an overview of the current research in this domain and guidelines for future investigations.

METHODS

We review current technologies in force measurement and haptic devices as well as their experimental evaluation and influence on user's performance.

RESULTS

Force sensing is moving away from the conventional proximal measurement methods to distal sensing and contact-less methods. Wearable devices that deliver haptic feedback on different body parts are increasingly playing an important role. Performance and accuracy improvement are the widely reported benefits of haptic feedback, while there is a debate on its effect on task completion time and exerted force.

CONCLUSION

With the surge of new ideas, there is a need for better and more systematic validation of the new sensing and feedback technology, through better user studies and novel methods like validated benchmarks and new taxonomies.

SIGNIFICANCE

This review investigates haptics from sensing to interfaces within the context of user's performance and the validation procedures to highlight salient advances. It provides guidelines to future developments and highlights the shortcomings in the field.

Surgeon-Centered Analysis of Robot-Assisted Needle Driving Under Different Force Feedback Conditions

Robotic assisted minimally invasive surgery (RAMIS) systems present many advantages to the surgeon and patient over open and standard laparoscopic surgery. However, haptic feedback, which is crucial for the success of many surgical procedures, is still an open challenge in RAMIS. Understanding the way that haptic feedback affects performance and learning can be useful in the development of haptic feedback algorithms and teleoperation control systems. In this study, we examined the performance and learning of inexperienced participants under different haptic feedback conditions in a task of surgical needle driving via a soft homogeneous deformable object-an artificial tissue. We designed an experimental setup to characterize their movement trajectories and the forces that they applied on the artificial tissue. Participants first performed the task in an open condition, with a standard surgical needle holder, followed by teleoperation in one of three feedback conditions: (1) no haptic feedback, (2) haptic feedback based on position exchange, and (3) haptic feedback based on direct recording from a force sensor, and then again with the open needle holder. To quantify the effect of different force feedback conditions on the quality of needle driving, we developed novel metrics that assess the kinematics of needle driving and the tissue interaction forces, and we combined our novel metrics with classical metrics. We analyzed the final teleoperated performance in each condition, the improvement during teleoperation, and the aftereffect of teleoperation on the performance when using the open needle driver. We found that there is no significant difference in the final performance and in the aftereffect between the 3 conditions. Only the two conditions with force feedback presented statistically significant improvement during teleoperation in several of the metrics, but when we compared directly between the improvements in the three different feedback conditions none of the effects reached statistical significance. We discuss possible explanations for the relative similarity in performance. We conclude that we developed several new metrics for the quality of surgical needle driving, but even with these detailed metrics, the advantage of state of the art force feedback methods to tasks that require interaction with homogeneous soft tissue is questionable.